Purple Flower

Good Faith Estimate for Clinical Social Work Services

As a client seeking psychotherapy, you are responsible for confirming whether your insurance covers services, whether you have a deductible, and how large a deductible your insurance will require. 

If you choose not to use insurance or a sliding scale fee, clients can anticipate that weekly 60-minute psychotherapy sessions throughout the next 12 months at $125 per session for a total of 48 weeks taking into consideration availability (vacations, holidays, emergencies, sick time) for an estimated total of no more than $6000.  Based upon a fee of $125 per visit, if you attend one psychotherapy session per week, your estimated charge would be $500 for four visits provided over the course of one month; $1,000 for eight visits over two months; or $1,500 for 12 visits over three months. If you attend psychotherapy for a longer period, your total National Association of Social Workers – January 2022 estimated charges will increase according to the number of session and length of treatment.

You are entitled to receive this Good Faith Estimate of what the charges could be for clinical social work/psychotherapy services provided to you. While it is not possible for a clinical social worker to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute the bill. You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). You may contact me to let me know the billed charges are higher than the Good Faith Estimate. You can ask me to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you. For regular/recurring services such as psychotherapy you can provide a single GFE for the entire year as long as the estimate includes the expected scope of primary services including frequency, fee per visit and anticipated timeframe. There is no penalty to overestimate the charges. The GFE can only include recurring services that are expected to be provided within 12 months. The clinician must offer a new estimate for additional services beyond 12 months and discuss any changes between the initial and new GFE.